India's Public Policy Guidelines and Programs for the Welfare of its Senior Citizens: What more needs to be done?

Introduction

Prolongation of life and the resultant population aging is an offshoot of socio-economic development and public health interventions. This global phenomenon that shapes the demand on the health and social care system has profound social, economic, and political implications for a country, specifically in resource-limited settings like India. The world population has reached 8 billion as of 2022 with 10% being 60 years or older. India has nearly 138 million elderly persons (Aged 60 years or above) which is nearly 10.1% (rural-8.8%, urban-8.1%) of its total population. The proportion of the elderly population has increased to 10.1% in 2021 and is projected to further rise to 13.1% by 2031. There are more elderly females (71 million) than males (67 million) in the country. The old-age dependency ratio in rural (15.1) is more than in urban (12.4). According to the Periodic Labor Force Survey (PLFS) 2018- 19, approximately 65% of men and 18% of women aged 60-64 years were economically active. However, there was a significant disparity between rural and urban regions.

In rural areas, 72% of elderly men and 21% of elderly women were economically active. Whereas in urban areas, the economic activity participation rate was lower, with 51% of elderly men and 10% of elderly women being economically active. Literacy rates are more in urban (66.0%) than rural (31.6%) of the elderly population. Both the share and size of the elderly population are increasing over time. The trend of growth of the elderly population and dependency ratio are given in Figure 1 and Figure 2 respectively. The projected elderly population in 2050 is approximately 323 million. The proportion of older people is higher in developed regions of India.

Old age dependency (ratio of persons aged 60 years and above to the working age population) ratio reflects the dependency burden from the elderly (60+) and shows an increasing trend and is expected to increase by about 7 percentage points during 2001-2026[5]. A decline in immunity as well as age-related physiologic changes leads to an increased burden of communicable diseases in the elderly. Similarly, age is the single largest demographic influencer of many chronic non-communicable diseases like diabetes, coronary heart disease, hypertension, stroke, chronic obstructive pulmonary disease, Alzheimer's disease, osteoarthritis, osteoporosis, prostatic hypertrophy, cataracts, macular degeneration, cancer, etc. According to the evidence available, at least one chronic disease affects about 21% of the elderly population in India. 17% and 29% of elderly population suffer from a chronic disease in rural and urban areas respectively. According to the LASI research, around 37%, 11%, and 10% of elderly people aged 75 and beyond reported having diabetes, cardiovascular diseases, and lung disease respectively, with more or less similar rates for nutritional, metabolic, gastrointestinal (GI) and genitourinary infections. Elderly people from middle- and higher-income groups are prone to obesity-related health risks.

Further elderly become more vulnerable to doing work and earning money. With the increasing trend of nuclear families, elderly people are neglected. In many cases, the family member is left lonely in public places. The financial support system for the elderly is a crucial factor in determining well-being. The sample survey conducted by the National Sample Survey Office (NSSO) in 2004 reveals that two-thirds of the aged person depend on others for their day-to-day maintenance. The situation was worse for elderly females with about only 10% and 11% economically independent in rural and urban areas respectively whereas in the case of elderly males, 48% and 57% of them did not depend on others for their livelihood in rural and urban areas as reported by National Sample Survey (NSS) 75th Round. Considering the above issues, the Constitution of India has made certain provisions for the welfare of elderly people. There are also certain policies of the government of India that exist for the welfare of its senior citizens. The objective of this review is to analyze the existing policies for the welfare of elderly people and identify the areas that need attention, with specific attention to health, economic, and social security.

Methods

This review was carried out between May to August 2017. Search engines Google and Yahoo, and scientific databases like PubMed Central and ProQuest were searched using keywords like elderly, old age, senior citizen, welfare, scheme, policy, public policy, pension, programmes, programs, India. The resultant literatures were analyzed and summarized. The analysis is focused on three important aspects of old age welfare i.e. health care (service and insurance coverage), economic security (pension and financial assistance), and social security (care and dignity) in India. (Figure 3)

Results

The Government of India has initiated a number of initiatives for the welfare of the elderly people in India[table 1]. Following the observation of “International year for older persons” by the UN in 1999, the National Policy on Older persons was launched by India, with the primary goal of ensuring overall well-being of the elderly including societal position through provision of financial security (old age pension), heavily subsidized health care & health insurance coverage, shelter to the needy, welfare, protection against abuse and exploitation etc.

Additionally, an integrated program for older persons was launched to improve their quality of life and ideas of respite care homes, multi service centers, and mobile medical care, etc. took pace but with limited implementation. Since its Independence, India has launched an array of schemes for older people (12–20) (Figure 4) These schemes mostly target socio-economic security of the older people. Health is a state subject. Accordingly, various services to elderly are provided through primary, secondary and tertiary care health facilities. About 52.52 lakhs, 1.22 lakhs and 3.96 lakhs of elderly has been provided health care services through out-patient services, Indore admission and physiotherapy, respectively by the entire operational District Hospitals in India during 2016-17. In addition, 2.27 lakhs, 0.67 lakhs and 0.74 lakhs of elderly people were provided several home-based care and supportive devices. But these services may involve substantial out of pocket expenses. Rashtriya Swasthya Bima Yojana (RSBY) is a government sponsored Health Insurance Scheme launched in 2008 for the Below Poverty Line (BPL) families with the objectives to reduce Out of Pocket (OOP) expenditure on health and increase access to health care. Latter RSBY was expanded to cover other 11 defined categories of unorganized workers i.e., Building and other construction workers registered with the Welfare Boards, Licensed Railway Porters, Street Vendors, MNREGA workers who have worked for more than 15 days during the preceding financial year, Beedi Workers, Domestic Workers, Sanitation Workers, Mine Workers, Rickshaw pullers, Rag pickers, and Auto/Taxi Driver. This ambitious scheme aims to cover 70 million households by the end of the Twelfth Five Year Plan (2012-17). RSBY provides coverage to maximum five members including three dependents' children at Rs. 30,000 per annum per family as a family floater scheme. RSBY is only for hospitalization for specific disease conditions/intervention. RSBY also covers pre-existing conditions from day one and also covers transport expenses of Rs. 100/- per hospitalization subject to a maximum of Rs.1000/- per year per family. Under this scheme the beneficiaries need to pay only Rs. 30/- as registration fee for a year and rest is borne by Central and State Government. The healthcare services are given by both public and private hospitals.

Apart from RSBY, both private and public insurers have special paid schemes for older people as enlisted in the table 2.

The age of entry and maximum age of coverage in these schemes are tabulated in the following table 3 that shows non-uniformity in coverage age across the schemes. Some of the schemes also require enrolling before the age of 50 years. For the health security of employees of the organized sector, there are schemes like Health Services to Central Government Employees (CGHS), E.S.I. and state specific Health Care Services. There is also reverse mortgage by financial institutions and concessional travels for senior citizens to improve the quality of life.

For economic security Indira Gandhi National Old Age Pension Scheme, Social Pensions in Various States and Union Territories in India, The Unorganized Workers Social Security Act, 2008, Post- Retirement Benefits for Employees of Central & state Government, voluntary National Pension System, Atal Pension Yojana (APY) Scheme, Old Age Allowance etc. are available. During 2014-15; 40,715 and 1,24,598 beneficiaries were issued in fresh and revision pension cases respectively. In 2015-16, till 23 December 2015; 24,959 and 1,23,170 beneficiaries were issued in fresh and revision pension cases respectively. Most of the State Governments have notified the NPS for their employees as on 31st December 2015. The APY has a total of about 1.8 million subscribers and corpus of Rs.2.62 billion as on 31st December 2015. A total of 11. 28 million members/subscribers (including APY) have been enrolled under the National pension system till 31st December 2015.

The National Social Assistance Programme (NSAP)[table 4] ensures economic and food security to various vulnerable groups like destitute (> 65 years), widow (40-64 years), disabled (18-64 years), and family without breadwinner. It consists of Indira Gandhi National Old Age Pension Scheme (IGNOAPS) for destitute above 65 years old, Indira Gandhi National Widow Pension Scheme (IGNWPS), Indira Gandhi National Disability Pension Scheme (IGNDPS), National Family Benefit Scheme (NFBS) and Annapurna. It ensures minimum assistance to the vulnerable and needy population. Currently, 31.83 million people are covered under NSAP schemes in India with 23.95 million destitute senior citizens are covered under the IGNOAPS scheme. [Table-4]. There is wide variation in coverage of IGNOAPS across various states in India.

Antyodaya Scheme-Under TPDS, food grains at 35 kg per family per month are allocated by the Central Government to States/Union Territories for 6.52 core accepted number of Below Poverty Line (BPL) families including 2.43 core Antyodaya Anna Yojana (AAY) families for distribution at subsidized prices through Fair Price Shops[23]. Changing pattern of family system in India i.e. extended to nuclear family, as well as issue of small family norms (pressure on single child to look after parents and grandparents) has made older people more vulnerable. It is unfortunate that senior citizens are becoming the victims of their own children and suffering from abuse.[24] A study in Bhubaneswar, Odisha has found that the prevalence of elderly abuse is 31%,[25] and among these abused around half of them were abused by their own biological sons. The HelpAge India survey in 2014 also found that half of India's elderly (50%) are experiencing abuse[26]. Elder Abuse is a dark reality and mostly confined to the four walls. Another survey among youth in 2015 had found that one-third of them had experienced elder abuse among their relatives. Middle class and women suffered more as shown by this survey. While daughter-in-law was stated to be the major (34.7%- 50%) culprit of elder abuse [27]. This has called for higher state responsibility to look after the welfare of the older people to lead a dignified life. Experiencing and anticipating such abuse, India has introduced the Maintenance and Welfare of Parents and Senior Citizens Act, 2007, is a step forward to it [16]. The Act establishes the Maintenance Tribunal to provide speedy and effective relief to elderly persons, and also mandates the establishment of an old age home in every district and provides for the protection of life and property of the elderly.

Parents, Grandparents and senior citizens can claim maintenance (provision for food, clothing, residence and medical attendance and treatment; up to Rs. 10,000/- per month) either under Section 125 of the Criminal Procedure Code, 1973 or under this Act.; from adult children, adult grandchildren, adult relatives and adult legal heirs. This Act also imposes a fine of Rs 5,000 or imprisonment for 3 months or both on the responsible person for care, in case of failure to care or intentional abandoning of the senior citizen. Govt. has also released around 0.5 billion rupees for functioning of 875 Old Age Homes from 2013-14 onwards and it is benefiting more than 21000 beneficiaries.[16] Though this act has taken adequate measures to safeguard the interest of older people, there is limited evidence on its effective implementation.

Discussion

In developed nations, the resource, experience and expertise has resulted in better welfare of the senior citizens. Japan has 28% of world's oldest population aged 65 years and above, which is the largest share in the world[28]. The country is tackling the problem with innovative programs, such as comprehensive long-term-care insurance and robotic assistance.[29] Denmark provides free comprehensive medical and social care benefits at doorstep to its elderly financed through taxation.[30] In England, National Framework for older persons is a holistic elderly care approach aimed at providing quality care, adequate & health-care services, independence of elderly, promotion of healthy lifestyles, prevention of social isolation and social exclusion. Various schemes such as the pension scheme, carers' allowance for the caregiver of elderly, meals on wheels for people who are unable to cook for themselves, and elderly day care centers to provide their social needs so that geriatric population.[31] Cuba with a rapidly aging population has a "cradle to grave" health-care system supported by the government and provides free health care and includes continuous follow-up and referral of elderly. Cuba conducts special sessions among the families to increase respect and consideration for the elderly[32.] Apart from healthcare there are a number of social and economic schemes available for the welfare of its senior citizens. Similarly other developed nations have comprehensive elderly welfare schemes.

In India, health is a state subject, and hence the care for elderly is non-uniform across the states depending on state resources and health facilities. Till date the majority of district hospitals are unable to provide specialty care for elderly. Also, health care being dominated by the private sector, it is very unlikely the government will be successful if only public sector facilities are promoted for specialty geriatric care.[11] For the same reason it is also difficult for RSBY to provide respite to all the eligible beneficiaries. Despite of the advantage of portability and cashless facility, RSBY is not universal. Additionally private sector insurance schemes do not address the equity issues by depriving high risk senior citizens by limiting the age of coverage and maturity.

As far as economic security through pension and financial assistance is concerned, there is limited incentive to invest in pension schemes as wealth creation, availability and its use is at times a difficult phenomenon. Therefore, there is a need to simplify NPS, PPF, EPF schemes for its timely use by the beneficiaries. The assistance under various NSAP schemes is around 1/20th of the monthly maintenance provisioned under the Maintenance and Welfare of Parents and Senior Citizens Act, 2007. Though increasing the amount of financial assistance under various NSAP schemes may constrain the economic development of the country, however ab appropriate strategy may be undertaken to protect the economic interest of the elderly[13].

According to the United Nations population division, the proportion of older adults aged 60 and above in India is projected to rise significantly from 10.11% to 21.5% by 2050, indicating a substantial increase in the elderly population to approximately 320 million[33]. This mandates effective and efficient implementation of our geriatric health policy and scale-up programs so that the elderly in our country will have a dignified and good quality life. The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 has made the provision of establishment of a Tribunal by the state at Sub-Divisional Level and headed by a revenue officer,[16] who may be overburdened and may have limited knowledge to adjudicate the matter as per civil procedure. This Act also empowered the state to represent the senior citizen but other parties are devoid of such benefits. The appeal also can be filed only by the senior citizen, not the other party. This may raise the issue of violation of natural justice and lead further litigation.[34] This Act also directs the government to provide medical support to the senior citizens; at a hospital headed by a medical officer having experience in Geriatric care is nearly impossible because of limited expert availability and also may result in limited access to care. The treatment by geriatrics may be costly also [16,34].

The challenges of ageing population and socio-economic development can be handled by stakeholders like government, civil society, academicians and others who are concerned about such issues in a more challenging, positive and collaborative manner. The National PolicyOlderPersons (NPOP), National Social Assistance Programme (NSAP), Annapurna program, old age homes, day care centers, travel discounts, income tax rebates, etc., are some of the initiatives taken by the government towards the problem of socio-economic security of the elderly[35]. The benefits of these programmes have been questioned several times due to poor awareness about such benefits among elderly, small budget, inappropriate identification of beneficiaries, restricted accessibility, difficult procedures, irregular payments, etc. Considering the growing trend of elderly population and its serious implications, it has become clear that the government alone cannot tackle the problem on its own. There have to be schemes that can assist voluntary organizations, welfare associations and communities to help the senior citizens with sincerity and commitment. There is a need to recognize them as a resource group and to develop suitable policies and programmes for their integration into the development process. The government should implement a program for ageing people on awareness and give knowledge on economic status. It is required that governments at Central, state and local level frame their policies keeping in view the demographic, social and economic changes in India.

Conclusion

There exists a huge gap in both supply and demand side in spite of a National Policy on Older Persons, 1999 (under revision), a National Council of Senior Citizens, an Integrated Program for Older People (maintenance of old age homes and respite care homes; multi service centers, mobile Medicare unit, dementia day care center, multi facility care center for older widows, physiotherapy clinics, help lines and counselling , programme for Sensitization, awareness projects for, formation of senior citizen associations/ self-help groups) and various financial, social, and health care schemes for the elderly run by various Ministries. Interstate variations in performance, poor public perception of ageing, their rights, and benefits are adversely affecting the schemes.

Ethics

Since the article utilized publicly available data, hence, an ethics approval was not required.

Declaration of Conflicting Interests

The Author(s) declare(s) that there is no conflict of interest.

Source of Funding

Nil

Acknowledgment

I am thankful to Miss Kalolini D Samant and Mr. Hitesh Kumar Jain for their valuable inputs and suggestions.

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